Honoring Advance Directives After a Suicide Attempt: A Review of Ethical and Practical Challenges

Abstract: Background/Significance:

Consultation-liaison psychiatrists are occasionally asked to determine whether patients’ decisions to forgo treatment are suicidal in nature or an expression of their values and goals of care. Although advance directives (AD) may help elucidate the patient’s authentic wishes, they can also introduce moral and ethical dilemmas (Nowland et al., 2019). We explore the latter by examining the management of patients with evidence of suicidality and AD limiting life-sustaining treatment.



Methods:

We conducted a review of literature exploring medical decision-making challenges and ethical dilemmas arising in the management of patients with AD who present after a suicide attempt. We searched PubMED, MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, and Web of Science. Titles and abstracts were screened by one author (KS) to identify papers highlighting real patient cases involving the use of AD after a suicide attempt. These were read in full by two authors (KS & MM) who independently determined which papers should be included in the final analysis using predetermined inclusion-exclusion criteria. Any disagreement was arbitrated by the third author (DD). A description of each patient case included in the final analysis was summarized in a table. An inductive thematic analysis was conducted to identify ethical dilemmas/questions that emerged while attempting to honor AD in this population.



Results:

The initial search yielded 1,511 articles. After removing duplicates and papers related to euthanasia, physician-assisted suicide, and medical aid in dying, 460 titles/abstracts were screened. 35 papers were selected for full review; an additional four were identified by scanning their references. We are currently reviewing this set of 39 papers to determine which will be included in the final analysis. The summary of patient cases is concurrently underway. The thematic analysis is pending. We anticipate completing our analyses by June 30, 2024.



Discussion:

We hypothesize that there will be a range of responses when it comes to the medical management of patients with an AD who attempt suicide depending on the type of AD, available collateral, likelihood of recovery, and perceived quality of life after the suicide attempt. Although we are taking an inductive approach to the thematic analysis of ethical dilemmas, we anticipate finding some themes identified in prior research (Nowland et al., 2019), including challenges in balancing autonomy and beneficence, honoring AD while complying with local laws, and applying AD to a suicide attempt.



Conclusion/Implications:

Consultation-liaison psychiatrists are occasionally asked to arbitrate clinical ethical dilemmas at the end of life, particularly when there is evidence of suicidality or there is no designated ethics consultation service available. This review aims to familiarize psychiatrists with the spectrum of responses in managing patients with an AD presenting after a suicide attempt, and to highlight the ethical dilemmas that psychiatrists may encounter when consulted on such cases.